The Journal of Emergency Medicine

Editorial Board

2010-01-01

Issue Highlights

2010-01-01

Partial Contents

2010-01-01

The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients

2008-08-08

Abstract: Background: Cardiac troponin elevations are associated not only with acute coronary syndromes (ACS) but also with multiple other cardiac and non-cardiac conditions. Study Objectives: To investigate the etiology and clinical significance of cardiac troponin I elevations in an unselected Emergency Department (ED) patient cohort. Methods: The study population consisted of 991 consecutive troponin-positive patients admitted to the ED of a university hospital with ACS as the presumptive diagnosis. Cardiac troponin I was measured on admission and a follow-up sample was obtained at 6–12 h. Clinical diagnosis was ascertained retrospectively using all the available information including electrocardiogram, clinical data, laboratory tests, and available coronary angiograms. Results: At admission, 805 (81.2%) patients were already troponin positive; of these, the troponin elevation was related to myocardial infarction (MI) in 654 (81.2%) patients. Finally, 83.0% of the troponin elevations were due to MI, 7.9% were related to other cardiac causes, and 9.1% to non-cardiac diseases. The leading non-cardiac causes were pulmonary embolism, renal failure, pneumonia, and sepsis. Non-cardiac patients with elevated troponin I at admission showed significantly higher in-hospital mortality (26.7% vs. 13.4%, p = 0.002) compared to cardiac patients. Conclusion: Elevated troponin levels for reasons other than MI are common in the ED and are a marker of poor in-hospital prognosis.

Community-Associated CMRSA-10 (USA-300) is the Predominant Strain Among Methicillin-Resistant Staphylococcus aureus Strains Causing Skin and Soft Tissue Infections in Patients Presenting to the Emergency Department of a Canadian Tertiary Care Hospital

2008-03-07

Abstract: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen first described among individuals with no contact with health care facilities. The purpose of this study was to determine the proportion of CA-MRSA, defined by pulsed field gel electrophoresis (PFGE), in MRSA skin and soft tissue infections presenting to the Emergency Department (ED). We also aimed to describe the laboratory and clinical characteristics of CA-MRSA infections. From June 1, 2001 to May 30, 2005, MRSA isolates from skin and soft tissue infections presenting to the ED were reviewed. They were characterized by antibiotic susceptibilities and PFGE, and the presence of staphylococcal cassette chromosome (SCC) mec type IVa and Panton-Valentine leukocidin (PVL) genes was assessed on representative isolates. The medical records were reviewed to define risk factors. There were 95 isolates available for analysis, of which 58 (61%) were CMRSA-10 (USA-300), the predominant clone from 2003 onward. All representative isolates (24%) tested in this group had PVL genes and SCCmec type IVa. Their antibiogram showed 100% susceptibility to trimethoprim-sulfamethoxazole, rifampin, and fusidic acid, and 79% to clindamycin. Clinical comparison of CMRSA-10 vs. hospital PFGE type strains showed 22% vs. 60%, respectively, for recent antibiotic use (p < 0.0001), 26% vs. 6%, respectively, for intravenous drug use (p < 0.05), and 57% vs. 6%, respectively, for soft tissue abscess (p < 0.001). CMRSA-10 is a major pathogen in skin and soft tissue abscesses in our ED. It has a characteristic susceptibility, and was associated with intravenous drug use, but not with recent antibiotic usage.

Motor Vehicle Crashes: The Association of Alcohol Consumption with the Type and Severity of Injuries and Outcomes

2008-06-12

Abstract: The effect of alcohol ingestion on short-term outcomes for trauma patients is indeterminate. Experimental and clinical reports often conflict. The objective of this study was to investigate the prevalence of positive alcohol screens, the effect of alcohol ingestion on injury patterns, severity, and outcomes in patients who were involved in motor vehicle crashes (MVC). MVC patients aged > 10 years treated in any of the 13 trauma centers in Los Angeles County during the calendar year 2003 were studied. All patients underwent routine alcohol screening on admission. The alcohol negative group (“no ETOH”) had a blood alcohol level (BAL) of ≤ 0.005 g/dL. Low and high alcohol groups (“low ETOH” and “high ETOH”) had a BAL of > 0.005 g/dL to < 0.08 g/dL and ≥ 0.08 g/dL, respectively. Logistic regression was performed to compare injury severity, complications, survival, and length of hospital stay among the three groups. Of the 3025 patients studied, 2013 (67%) were in the no ETOH group, 216 (7%) were in the low ETOH group, and 796 (26%) were in the high ETOH group. Levels were not associated with injury severity, Emergency Department hypotension, or Intensive Care Unit length of stay. Patients with an injury severity score > 15 and a high BAL had a higher incidence of severe head trauma (head abbreviated injury score > 3) and increased incidence of sepsis. However, in this group of severely injured, the high ETOH group had a significantly better survival rate than patients in the no ETOH group (adjusted odds ratio 0.41, 95% confidence interval 0.16–0.94, p = 0.05). Severely injured MVC victims with a high BAL have a higher incidence of severe head trauma and septic complications than no ETOH patients. However, the high ETOH group had superior adjusted survival rates.

Acute Myocardial Infarction Related to Methylphenidate for Adult Attention Deficit Disorder

Jan Thompson, James R. Thompson — 2007-11-19

Abstract: Adult Attention Deficit Disorder is increasingly diagnosed and treated. Psychostimulant medications, such as methylphenidate, are commonly prescribed for this condition, but the long-term safety of such medications in an adult population is unknown at present. Because these medications are closely related to amphetamines, it is expected that toxic side effects would be similar. We present the case of a 27-year-old man who suffered an acute myocardial infarction due to coronary vasospasm related to use of methylphenidate complicated by concomitant use of pseudoephedrine.

Phantom Shocks in Patients with an Implantable Cardioverter Defibrillator

Emerson A. Juan, Marc Pollack — 2008-04-07

Abstract: Phantom shock is the sensation of shock in the absence of an actual implantable cardioverter-defibrillator (ICD) discharge. The ICD is now the first–line therapy for patients with ventricular tachycardia and fibrillation. There has been a significant increase in the number of patients with an ICD and patients presenting to the Emergency Department (ED) after a shock for evaluation and device interrogation. Phantom shock is more likely to be nocturnal in the first 6 months after implantation, and patients are more likely to be clinically depressed and have higher levels of anxiety. There is no specific treatment. We report 3 patients who presented to the ED with the sensation of ICD discharges, however, on device interrogation had no shocks and no dysrhythmias.

Spontaneous Acute Subdural Hematoma and Chronic Epidural Hematoma in a Child with F XIII Deficiency

Murat Vural, Coskun Yarar, Ramazan Durmaz, Metin Ant Atasoy — 2008-06-03

Abstract: Factor XIII (F XIII) deficiency is a rare autosomal recessive congenital disorder that can cause spontaneous subdural or epidural hematomas. Due to its low incidence, F XIII deficiency may well be under-diagnosed. A 7-year-old girl with no history of medical problems presented with progressive headache of 3 days. Cerebral computed tomography (CT) scans revealed a large right acute parietooccipital subdural hematoma with a significant midline shift. After an emergent parietooccipital craniotomy and evacuation of the subdural hematoma, a screening test for factor XIII was performed. The results of the test were abnormal. She had full recovery and was discharged with a follow-up treatment of monthly transfusion of fresh frozen plasma as the replacement and prophylactic therapy. Ten months later, she was referred to our center with headache after a minor head trauma. Her medical history revealed that she had not received fresh frozen plasma for the last 2 months. CT scan showed a chronic right parietal epidural hematoma beneath the craniotomy flap. The present case indicates that although its incidence is very rare, F XIII deficiency can cause acute or chronic subdural and epidural hematomas. Therefore, in acute or chronic subdural and epidural hematomas with no underlying cause, the presence of a potential F XIII deficiency should be suspected as a cause of hemorrhagic diathesis.

Endometriosis Presenting as Bloody Ascites and Shock

2008-05-22

Abstract: Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patient's condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock.

Severe Amlodipine Intoxication Treated by Hyperinsulinemia Euglycemia Therapy

Hicham Azendour, L. Belyamani, M. Atmani, H. Balkhi, C. Haimeur — 2008-07-28

Abstract: The objective of this study was to report a use of hyperinsulinemia euglycemia therapy in severe amlodipine intoxication. Intoxication with 420 mg of amlodipine caused severe hypotension in a 20-year-old female patient. The patient was initially treated with fluids, calcium gluconate, and epinephrine without effect. She was then given hyperinsulinemia euglycemia therapy. We observed a rise in blood pressure (BP) approximately 30 min after insulin was given and the BP was subsequently responsive to epinephrine. The patient was weaned from pressors 5 h after insulin therapy. The trachea was extubated 24 h after ingesting amlodipine, and the patient was transferred for psychiatric treatment 3 days later. This possible positive inotropic effect of insulin therapy in patients with calcium channel blocker intoxication supports previous findings. It is suggested that hyperinsulinemia euglycemia therapy may be considered as a first-line therapy in amlodipine intoxication.

Radiographic Look-Alikes: Distinguishing Between Pneumoperitoneum and Pseudopneumoperitoneum

Bruce M. Lo — 2008-09-01

Abstract: Background: Air under the diaphragm seen on plain radiograph usually signifies a perforated viscus. This represents a surgical emergency and an immediate consult with the surgeon. However, not all air under the diaphragm seen on plain radiograph represents a surgical emergency. Objectives: This article will present two cases with air under the diaphragm, but with different diagnoses and management. The first case is an example of pneumoperitoneum from a perforated viscus. The second case is an example of pseudopneumoperitoneum from Chilaiditi syndrome, which will be discussed. Case Reports: The first case is a 45-year-old woman who presented with bloating, nausea, and vomiting after being diagnosed with diverticulitis 4 days before evaluation. The patient was noted to be febrile and tachycardic. A chest radiograph was obtained, which showed air under the diaphragm. A surgeon was consulted who performed a laparotomy on the patient. Patient was diagnosed with a perforated viscus from a sigmoid diverticulitis. The second case is a 68-year-old woman who presented with right-sided abdominal pain, cough, nausea, and vomiting. A chest radiograph showed possible free air under the diaphragm. A computed tomography scan of the abdomen showed Chilaiditi syndrome, large bowel transposed between the liver and the diaphragm, but no free air. The patient was treated symptomatically and discharged home. Conclusion: It is important for physicians to be able to distinguish pneumoperitoneum and pseudopneumoperitoneum to allow proper diagnosis and treatment.

Revolutionary Advances in the Management of Traumatic Wounds in the Emergency Department During the Last 40 Years: Part I

2009-03-06

Abstract: Background and Objectives: This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. Discussion: The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. Conclusion: On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

A Nineteen-Year-Old Girl with Palpitations

Diana Felton, David Callaway, Carrie Tibbles, Daniel McGillicuddy — 2009-12-28

Dr. Diana Felton: Today's case is that of a 19-year-old girl who presented to the Emergency Department (ED) with palpitations for 2 h. She first noticed her “heart racing” 2 h prior, while watching television. She had no chest pain, shortness of breath, or lightheadedness. Before the onset of palpitations, she had been feeling well, without fever, malaise, or recent illness. She had never had palpitations before this episode. There was no drug use. She was a college student currently on semester break. She had no significant medical history and took no prescribed or over-the-counter medications.

Emergency Ultrasound in Cervical Ectopic Pregnancy

Timur Kouliev, Karen Cervenka — 2008-07-10

A 41-year-old G4P3 woman presented to the Emergency Department with vaginal pain and spotting for 24 h. She reported a total loss of one pad of blood and severe vaginal pain without significant abdominal discomfort. Her last menstrual period was 6 weeks prior; she had no history of sexually transmitted infections, and reported a normal Pap smear a year previously. Past medical history was significant for Hodgkin's lymphoma in remission for 12 months. Obstetrical history was significant for a vaginal delivery and two subsequent elective cesarean sections.

Tension Pneumoperitoneum

Brian W. Lin, Wendy Thanassi — 2008-06-24

A 74-year-old woman was transferred by ambulance from a nearby general medicine clinic to the Emergency Department (ED) for decreased blood pressure and abdominal pain. The patient had been undergoing a colonoscopy for persistent heme-positive stools. Shortly after insufflation of the colon, she began to complain of severe diffuse abdominal pain. On arrival in the ED, she had an initial right arm blood pressure of 85/45 mm Hg. Her physical examination was remarkable for a tense, distended abdomen. She had warm, pink upper extremities and mottled, cyanotic lower extremities with diminished pulses. Abdominal radiographic images were obtained ().

Positive Cerebral Spinal Fluid Cultures with Normal Cell Count and Gram Stain

Ashley M. Maranich, Martin Weisse — 2009-08-10

We read with great interest the article by Boysen et al. regarding cerebral spinal fluid (CSF) culture results (). In the article, the authors conclude that immunocompetent patients evaluated for meningitis with a lumbar puncture do not require follow-up for a positive CSF culture if the cell count and Gram stain are normal. We find this troubling, as such a dismissal of a positive CSF culture could have serious clinical implications.

Reply to Maranich and Weisse

Megan Boysen, Scott Rudkin, Michael Burns, Mark Langdorf, Jeffrey Henderson — 2009-08-17

We appreciate and respect Drs. Maranich and Weisse's critique of our article. We concede that a single, especially retrospective, study should not change patient management. Our conclusions were purposely measured, and include, “seem to be reliable,” “if validated prospectively,” and “may be unnecessary.”

No Opiates for Headache—Reply

Frank W. Lavoie — 2009-10-05

As an emergency physician and hospital administrator, I read with interest Dr. Rosen's well-articulated views regarding the management of opiate-seeking emergency department patients. Dr. Rosen's assertion that each patient should be afforded the best care the physician can deliver devoid of both rote and judgmental thinking is an imperative aspect of professional practice that not only protects the physician's personal well-being, but also protects the patient's best interests. However, the one portion of Dr. Rosen's commentary with which I disagree and that I do not find congruous with the remainder of his argument appears in the second-to-last paragraph, wherein he recommends that physicians use “THEY” to absolve themselves from taking responsibility for the decision to withhold narcotic administration or prescription. I believe that such denial of responsibility is inherently unprofessional. Such actions corrupt the physician's self-image and simply compound the problem by encouraging an affected individual to file complaints with Administration (the “THEY”) or complaints with regulatory agencies against the facility, alleging that it blocks physicians from providing appropriate therapy. Sure, emergency physicians have difficult patients and work in a difficult environment. So do surgeons, social workers, and many other members of our society. Nevertheless, as professionals, we must take responsibility for our professional judgments and decisions. I would offer that a statement such as “WE cannot give you that as your condition doesn't meet the requirements that OUR facility has established for narcotic use,” or something similar, is not only more accurate, but also allows emergency physicians to take responsibility for the assessments we are making. To blame the facility, administration, or some other body not present to participate in the decision-making process is not the optimal answer to this difficult problem.

Reply to Letter to the Editor on the Management of Headaches without Opiates

Peter Rosen — 2009-09-10

Thank you, Dr. Lavoie, for your interesting observations concerning my reflections on the management of patients with headaches. I respect your advice about not referring responsibility to administration, but that was not my intent when invoking the “they” rule. My goal is to avoid confrontations with patients: “You want something, and I have the power to say NO!” This leads to more complaints to administration than does citing the more nebulous unnamed authorities. In fact, the only letters of complaint that I have received about pain management over the course of my almost 50 years of practice have been from patients for whom I directly refused pain medications. Moreover, in not one instance of these complaints was I ever supported by the administration.

Re: Peter Rosen's Recent Piece

Keith Stamler — 2009-09-10

I found the recent Emergency Forum article, “No Opiates for Headache,” by Peter Rosen to be quite memorable, indeed. I was anxious to learn Dr. Rosen's insights into a problem we all deal with, that of opiate use for headaches, a complaint with no objective physical findings. The first half of the article had little, if anything, to do with the subject. Rather, it was a series of interesting reflections upon his long career, and his changing attitudes and responses to the “problem” patients—“the uninsured, the derelicts, and the chronic psychiatric diseases” that are a part of every emergency physician's job. The piece then transitions to the headache-opiate problem. What is the best way to deal with this vexing issue, and its confrontations, power issues, repeat work-ups, and the “frequent flier” card box? Dr. Rosen offered his thoughts.

Reply to Letter to the Editor by Dr. Stamler

Peter Rosen — 2009-09-10

I regret that Dr. Stamler has misunderstood my joke. Had there been a Republican victory, I would have said Democrat. I think if he reads the article again, he will not apply my descriptions of the patients that I, and probably many other emergency physicians, have found troublesome to be based on their politics.

Cellulitis: Infectious or Non-Infectious?

Secgin Soyuncu — 2009-08-10

Cellulitis is an inflammatory disease that involves the skin and subcutaneous tissues and frequently leads to office visits and hospital admissions. Most cases of cellulitis can be attributed to an infectious cause. However, some underlying causes such as poor patient compliance, antibiotic resistance, underlying deep-seated infection, foreign body-related infection, and depressed immune status may cause challenging states of cellulitis that are resistant to conventional antimicrobial therapy. Just as infectious cellulitis must be considered, non-infectious causes also should be considered when faced with a challenging cellulitis. We report a case of a rare non-infectious cause of cellulitis that was resistant to antibiotics and improved by steroid therapy.

Do United States Medical Licensing Examination (USMLE) Scores Predict In-Training Test Performance for Emergency Medicine Residents?

Josef G. Thundiyil, Renee F. Modica, Salvatore Silvestri, Linda Papa — 2008-10-27

Abstract: Background: Residency selection committees commonly utilize USMLE scores as criteria to screen residency applicants. Objectives: The purpose of this study is to evaluate the relationship between United States Medical Licensing Examination (USMLE) and American Board of Emergency Medicine (ABEM) in-training examination scores (ITEs). Methods: In an Accreditation Council for Graduate Medical Education-accredited emergency medicine residency program, data were collected for this retrospective cohort study for the classes of 2002–2006. USMLE Step 1 and 2 scores and the ABEM ITEs were recorded for each post-graduate year (PGY) within the aforementioned time frame. Step 1 and 2 scores were compared to consecutive PGY ABEM ITEs to evaluate for an association. Results: There were 51 USMLE Step 1 and 39 Step 2 scores available for comparison with 153 ABEM ITEs. The mean USMLE Step 1 and Step 2 scores were 228.9 (range 197–252) and 228.4 (range 168–259), respectively. The mean in-training percentiles for the PGY 1, 2, and 3 years were 40.4, 68.3, and 81.7, respectively. The R-squared values for the Step 1 scores compared to the PGY 1, 2, and 3 years' ITEs were 0.25, 0.18, and 0.16, respectively. The R-squared values for Step 2 scores as compared to the ABEM ITEs for the PGY 1, 2, and 3 years were 0.43, 0.44, and 0.38, respectively. Residents who scored below 200 on either USMLE Step 1 or Step 2 had significantly lower mean ABEM ITEs than residents who scored above 200 (p < 0.05) and were 10-fold more likely than residents who scored above 220 to score below the 70th percentile in their PGY3 ABEM ITE. Conclusions: USMLE Step 1 scores are mildly correlated and Step 2 scores are moderately correlated with ABEM ITEs. Scoring below 200 on either test is associated with significantly lower ABEM ITEs.

Improving Service Quality by Understanding Emergency Department Flow: A White Paper and Position Statement Prepared For the American Academy of Emergency Medicine

2008-06-03

Abstract: Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues.

Clinical Decision Rules for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

2009-10-05

Abstract: Background: Out-of-hospital cardiac arrest (OHCA) has a low probability of survival to hospital discharge. Four clinical decision rules (CDRs) have been validated to identify patients with no probability of survival. Three of these rules focus on exclusive prehospital basic life support care for OHCA, and two of these rules focus on prehospital advanced life support care for OHCA. Clinical Question: Can a CDR for the termination of resuscitation identify a patient with no probability of survival in the setting of OHCA? Evidence Review: Six validation studies were selected from a PubMed search. A structured review of each of the studies is presented. Results: In OHCA receiving basic life support care, the BLS-TOR (basic life support termination of resuscitation) rule has a positive predictive value for death of 99.5% (95% confidence interval 98.9–99.8%), and decreases the transportation of all patients by 62.6%. This rule has been appropriately validated for widespread use. In OHCA receiving advanced life support care, no current rule has been appropriately validated for widespread use. Conclusions: The BLS-TOR rule is a simple rule that identifies patients who will not survive OHCA. Further research is required to identify similarly robust CDRs for patients receiving advanced life support care in the setting of OHCA.

American Academy of Emergency Medicine

2010-01-01

Comparison of Traditional Advanced Cardiac Life Support (ACLS) Course Instruction Vs. a Scenario-Based, Performance Oriented Team Instruction (SPOTI) Method for Korean Paramedic Students

2008-08-26

Abstract: Current Advanced Cardiac Life Support (ACLS) course instruction involves a 2-day course with traditional lectures and limited team interaction. We wish to explore the advantages of a scenario-based performance-oriented team instruction (SPOTI) method to implement core ACLS skills for non-English-speaking international paramedic students. The objective of this study was to determine if scenario-based, performance-oriented team instruction (SPOTI) improves educational outcomes for the ACLS instruction of Korean paramedic students. Thirty Korean paramedic students were randomly selected into two groups. One group of 15 students was taught the traditional ACLS course. The other 15 students were instructed using a SPOTI method. Each group was tested using ACLS megacode examinations endorsed by the American Heart Association. All 30 students passed the ACLS megacode examination. In the traditional ACLS study group an average of 85% of the core skills were met. In the SPOTI study group an average of 93% of the core skills were met. In particular, the SPOTI study group excelled at physical examination skills such as airway opening, assessment of breathing, signs of circulation, and compression rates. In addition, the SPOTI group performed with higher marks on rhythm recognition compared to the traditional group. The traditional group performed with higher marks at providing proper drug dosages compared to the SPOTI students. However, the students enrolled in the SPOTI method resulted in higher megacode core compliance scores compared to students trained in traditional ACLS course instruction. These differences did not achieve statistical significance due to the small sample size.

Doing Something by Doing Nothing

Adam J. Rosh — 2009-06-18

He is going to die by the end of my shift, I thought to myself as I examined Mr. Brenner. He was surrounded by his wife of 41 years, a daughter, and a son. I knew Mr. Brenner was deathly ill when I saw that he had recently been discharged from the hospital after complications from metastatic prostate cancer. He was diagnosed nearly 3 years ago. He thought it was in remission, he said, but the cancer showed its ugly face again 6 months ago when Mr. Brenner started having lower back pain. He thought the pain was from years of lifting concrete bags as a construction worker, but discovered it was caused by the collapse of one of his vertebras.

Unique Sexual Assault Examiner Program Utilizing Mid-Level Providers

Elliot C. Pennington, Frank L. Zwemer, Dolores A. Krebs — 2008-08-08

Abstract: Background: We implemented a unique sexual assault examiner (SAE) program utilizing Emergency Department (ED)-based mid-level providers. Sexual assault forensic evidence collection processes and training are not uniform in all EDs, with varying models in place. Methods: Our study evaluated the quality of SAE evidentiary collection in standardized evidence kits (Kits), compared to Kits from other EDs without the SAE program. We prospectively studied Kits from November 2004–October 2005. All Kits were evaluated for quantity (numbers of slides, envelopes, swabs), and quality (compliance with forensic standards) of evidence. Results: Although SAE Kits had similar total numbers of pieces of evidence, they had higher quality as measured by a greater number of compliant envelopes (5.44 vs. 1.44, p < 0.001) and a greater number of compliant slides (6.4 vs. 4.5, p < 0.001). SAE Kits had two measures with higher quality forensic evidence than non-SAE Kits. Conclusion: An integrated program of SAE-trained mid-level providers collect sexual assault Kits with a higher quality of forensic evidence than non-SAE providers.

Intravenous Tissue Plasminogen Activator for Stroke: A Review of the ECASS III Results in Relation to Prior Clinical Trials

Carolyn A. Cronin — 2009-09-18

Abstract: Background: Intravenous tissue plasminogen activator (IV tPA) is currently approved by the Food and Drug Administration for use in acute ischemic stroke patients up to 3 h from symptom onset, based primarily on the National Institute of Neurological Disorders and Stroke tPA trials published in 1995. The most recent trial published with IV tPA in stroke (European Cooperative Acute Stroke Study [ECASS] III) studied patients between 3 and 4.5 h from symptom onset and found a benefit to treatment in the rate of favorable outcome when compared to placebo, with no difference in mortality. Objectives: To examine the patient selection criteria and primary outcomes in ECASS III as compared to prior clinical trials and the current practice in the United States to determine how these new data could be applied to clinical practice. Discussion: With the exception of the longer time from symptom onset to treatment, ECASS III used more restrictive patient selection criteria than is the current practice in the United States to determine patient eligibility for IV tPA. Conclusions: Based on the combined data from all trials, the benefits of thrombolysis with IV tPA for acute ischemic stroke outweigh the risks of treatment for selected patients up to 4.5 h from symptom onset. It is already known that thrombolysis is not beneficial for all stroke patients and strict criteria should be applied before treatment. As time from symptom onset increases, the need for careful patient selection likely also increases.

Carl J. Smith, J. Christian Fox, Shahram Lotfipour — 2009-03-02

The use of bedside ultrasound in the emergency setting has rapidly become the standard of care for detecting various pathologies. It has become essential for Emergency physicians to be proficient in the clinical application of bedside ultrasonography (US). Challenger's EM Ultrasound is a CD-ROM course designed to teach the basic techniques, capabilities, and interpretations of emergency US to emergency and acute care physicians. Author John Kendall, md, facep, is currently the Director of Emergency Ultrasound at Denver Health Medical Center. Dr. Kendall and co-authors Stahmer and Deutchman effectively use clear audio, video, and still US imagery, multimedia, and three-dimensional animations to teach the emergency US examinations.

Brianna Iversen — 2009-03-26

The Oxford American Handbook of Obstetrics and Gynecology is aimed at being a quick reference text for use by clinical practitioners at all levels of practice. There are many extensive and comprehensive texts about the specialty out there; however, many of these are not search-friendly. This is where this book tries to find its niche. The handbook is designed to be a compact and easy guide to obstetrics and gynecology that provides a wide-ranging overview of the specialty. The need for a pocket guide is a practical one for busy clinicians and medical students alike. It is not always convenient to bring out the large bulky texts from your collection on the shelf when you need a quick answer. However, this can be a daunting task to take on. Because the field itself encompasses a massive amount of information, manipulating it into a compact yet useful text has many challenges.

Coronary Artery Calcification Screening: Estimated Radiation Dose and Cancer Risk: Kim KP, Einstein AJ, Berrington de Gonzalez A, et al. Arch Intern Med 2009;169:1188–94

Bonnie Kaplan — 2010-01-01

This collaborative, multi-center study examined the risks of radiation from multidetector computed tomography (CT) used for the screening of coronary artery calcification. There are no current detailed estimates of safe radiation doses for this type of CT scan. Given this fact, the authors used risk models compiled by the National Research Council's Biological Effects of Ionizing Radiation VII committee, as well as databases drawn from the Life Span Study of Japanese atomic bomb survivors and from patients irradiated in the course of medical treatment. This information was used to estimate the risk of cancer against typical incidence according to age or gender. Their goal was to estimate the potential, organ-specific cancer risks from the radiation used in these CT scans. Because the CT scan radiation protocols have not been standardized, the authors used the scan protocols from Columbia University, New York-Presbyterian Hospital, Cleveland Clinic, and Penn State University Hospital. Taking into account the Screening for Heart Attack Prevention and Education (SHAPE) guidelines, the authors estimated radiation-associated cancer risk from a single CT screening from these four hospitals. They then estimated the risk if the CT screening were to be repeated every 5 years. Age and gender were controlled variables. There was a 10-fold variation in radiation dose between the four different hospital protocols. This wide variation resulted in a large difference in estimated cancer risk from the different radiation protocols. Using the SHAPE guidelines, men had 42 per 100,000 (range, 14–200) cancer risk, whereas women had a 62 per 100,000 risk (range, 21–300 cases). These cancer risks decreased when people started screening at an older age and therefore had less lifetime radiation exposure. The lungs had the highest cancer risk, 72% for men and 71% for women; then breast for women (20%), and finally, leukemia (12% for men and 4% for women). The authors concluded that standardization of low-dose radiation protocols is exceedingly important for screening CT scans, to decrease the amount of radiation exposure and thereby minimize the risk of cancer.

The Dissociation Between Door-to-Balloon Time Improvement and Improvements in Other Acute Myocardial Infarction Care Processes and Patient Outcomes: Wang TY, Fonarow GC, Hernandez AF, et al. Arch Intern Med 2009;169:1411–9

Janetta Iwanicki — 2010-01-01

This retrospective observational study examined data from 101 hospitals from 2005 to 2007 to determine whether an improvement in door-to-balloon time was significantly correlated with other measures of improvement in care of patients with acute myocardial infarction. These other measures included the Joint Commission on Accreditation of Healthcare Oragnizations and Centers for Medicare and Medicaid Services core measures such as patients receiving aspirin and beta blockers, as well as in-hospital mortality. In 101 hospitals, a total of 5881 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were examined. Of these patients, 3278 were in the early period and 2603 were in the late period. The overall geometric mean door-to-balloon time significantly decreased from 101 to 87 min between the two time periods (p < 0.001). Hospitals were ranked in quartiles based on their change in door-to-balloon time for broad trends, but were also analyzed individually. The mean composite score of compliance with core measures for all hospitals also improved significantly between the early and late time periods, increasing from 93.4% to 96.4% (p < 0.001). Overall in-hospital mortality improved but did not reach statistical significance from 5.1% to 4.7% (p = 0.09). However, Spearman correlation coefficients and multivariate logistic regression analysis did not reveal a statistically significant correlation between either improvement in door-to-balloon time and improvement in core measure composite score (p = 0.55) or improvement to in-hospital mortality rates (p = 0.58). There was a trend toward significance in decreased in-hospital mortality for hospitals with improvement in both door-to-balloon time and core measures compliance (p = 0.07). The authors conclude that focusing solely on improving the single quality measure of door-to-balloon time does not improve overall outcomes. Possible explanations for this finding include diversion of resources from other quality-improvement measures, ease of improving door-to-balloon time compared to improving other quality control measures, and multitude of factors with impact on in-hospital mortality.

Adenosine for Wide-Complex Tachycardia: Efficacy and Safety: Marill KA, Sigrid W, deSouza IS, et al. Crit Care Med 2009;37:2512–8

Charles M. Reynolds — 2010-01-01

In this study, 197 patients received adenosine for wide complex tachycardia, defined as tachycardia with a QRS duration > 120 ms lasting more than 2 min. Nine urban hospitals participated in this multi-center, retrospective, observational study over 15 years, from 1991–2006. Supraventricular tachycardia (SVT) correlated strongly with a response to adenosine (104 [90%] out of 116 patients). Conversely, adenosine had no effect in patients presenting with ventricular tachycardia (VT), with only 2 (2%) of 81 patients demonstrating a response. Response to adenosine increased the likelihood of SVT by a factor of 36, whereas resistance to adenosine increased the likelihood of VT by a factor of 9. Of the group of patients with VT, none had an adverse event, defined as need for emergent electrical or medical therapy, suggesting that the use of adenosine in wide complex tachycardia is a safe practice.

An Outbreak of Varicella in Elementary School Children with Two-Dose Varicella Vaccine Recipients–Arkansas, 2006: Gould P, Leung J, Scott C, et al. Pediatr Infect Dis J 2009;28:678–81

Morgan Pinkston — 2010-01-01

This study investigated the difference between the one- and two-dose vaccine effectiveness after a varicella outbreak at an Arkansas school between September 1 and December 18, 2006. Of the 880 children attending the school, 871 had known vaccination status. Vaccination was defined as receiving the vaccine at least 42 days before rash onset. Ninety-seven percent of these children were vaccinated, of which 58% had one-dose coverage and only 39% had two-dose coverage. Although vaccination status was identified by Arkansas vaccine registry, the number of cases was identified through returned questionnaires (696 returned out of 880). The presence of at least three lesions was necessary in parental diagnosis of disease. Eighty-four children were documented as positive, of which 25 had been vaccinated with two doses, 53 with one dose, and six were unvaccinated but with positive history of disease. The attack rate of the one-dose (10.4%) and the two-dose (14.6%) were not significantly different (RR: 0.72, 95% confidence interval 0.44–1.15). Thirteen percent of one-dose subjects contracted moderate disease (51–249 lesions), and all other subjects in both groups indicated mild disease (3–50 lesions) on questionnaires. No subjects required hospitalization, therefore, the presence of either one- or two-dose vaccination seemed to prevent severe disease. The authors question whether a higher two-dose group within the school would have prevented the outbreak from occurring.

An Unseen Danger: Frequency of Posterior Vessel Wall Penetration by Needles During Attempt to Place Internal Jugular Vein Central Catheters Using Ultrasound Guidance: Blaiva M, Adhikari S. Crit Care Med 2009;37:2345–9

Bonnie Kaplan — 2010-01-01

This prospective, single-blinded study evaluated for posterior vessel wall penetration during ultrasound-guided internal jugular (IJ) catheter placement. It was conducted at an urban Level I trauma center with emergency medicine residents. The 25 residents that participated in the study had more than 2 years experience in ultrasound, performed more than 100 ultrasound-guided vascular-access procedures before the study, and participated in a 2-day ultrasound-training course. Each resident was asked to place an IJ catheter using ultrasound guidance in the short access view on life-sized torso models. An endocavity transducer was used to observe the placement of the needle. Investigators recorded penetration of more than one wall of the internal jugular, penetration of the adjacent carotid artery, and final location of the needle tip in the vein. The main outcome measure was posterior wall penetration. The secondary study outcome measure was the final position of the needle tip. All residents completed the procedure. Sixteen of the residents (64%) penetrated the posterior wall. Carotid cannulation happened in 5 cases. Six cases showed a needle deep to the vein. Residents with more training and prior ultrasound-guided catheter experience had fewer posterior wall penetrations (p = 0.04). The authors concluded that although data were not statistically significant, care should be taken, even when using ultrasound-guided central catheter placement. Supplemental ultrasound techniques should be considered to ensure safe IJ placement.

Exposure to Low-Dose Ionizing Radiation for Medical Imaging Procedures: Fazel R, Krumholz HM, Wang Y, et al. N Engl J Med 2009;361:849–57

Janetta Iwanicki — 2010-01-01

This retrospective cohort study examined claims for 952,420 insured adults between ages 18 and 64 years to determine population-based rates of annual cumulative effective doses of radiation received for radiologic procedures. Of the total number of eligible adults, 655,613 patients underwent a procedure with radiation exposure. Investigators chose to examine the cumulative effective dose of radiation, defined as weighted measures of energy that affect each organ, type of radiation, and potential for future mutagenic degeneration for a given procedure, and these generalized doses were gleaned from the prior radiologic literature. Individual radiation exposure was therefore not measured, only estimated. Based on these data, the overall mean radiation dose was 2.4 ± 6.0 mSv for all included patients, with 1.2 ± 1.8 (95% confidence intervals) procedures per person annually. Salient trends include increased exposure in older patients with age > 60 years, and increased exposure in women. The authors defined low exposure as 0–3 mSv, moderate exposure as 3–20 mSv, high exposure as 20–50 mSv, and very high exposure as > 50 mSv. Procedures with highest effective doses delivered included computed tomography scans and nuclear medicine studies, including myocardial perfusion studies. Although most patients were categorized as low exposure (785.7 per 1000 enrollees), the authors express concern for the sizable minorities in moderate (193.8 per 1000 enrollees), high (18.6 per 1000 enrollees), and even very high exposure (1.9 per 1000 enrollees) categories. The authors conclude that medical procedures contribute a significant source of ionized radiation exposure to the general population, and that physicians must be vigilant regarding ordering only justified tests to reduce overall lifetime exposures.

Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Younger Patients: Mendu LM, McAvay G, Lampert R, et al. Arch Intern Med 2009;169:1299–305

Charles M. Reynolds — 2010-01-01

In this retrospective review, the authors reviewed the charts of 2106 consecutive patients at a single hospital to determine the diagnostic yield of ancillary testing in the evaluation of syncope. In addition, they determined the cost per test affecting diagnosis and management for commonly performed laboratory and radiographic tests. According to their calculations, the finding of postural hypotension had the greatest diagnostic yield, contributing to the diagnosis 26% of the time. Also high yield were telemetry (11%), electrocardiogram (7%), and the cardiac stress test (10%). Low-yield diagnostic tests included cardiac enzymes (2%), computed tomography (CT) of the head (2%), electroencephalogram (1%), and carotid ultrasound (1%). The authors calculated the cost per test affecting diagnosis, which was lowest for postural blood pressure measurement ($17), telemetry ($710), electrocardiogram ($1020), and echocardiogram ($6272). Cost per test affecting diagnosis was highest for electroencephalogram ($32,973), head CT scan ($24,881), and troponin-I ($22,397).

The Presence of a Family Witness Impacts Physician Performance During Simulated Medical Codes: Fernandez R, Compton S, Jones KA, et al. Crit Care Med 2009;37:1956–60

Morgan Pinkston — 2010-01-01

This study performed at Wayne State University School of Medicine sought to define the effects of family witnesses in emergency department resuscitation rooms. The study utilized simulated cases to identify the effect of witnesses on overall length of the resuscitation attempt, the time to critical events, such as intubation or defibrillation, and recognition of a drug error. The researchers divided 60 second-year and third-year emergency medicine residents into three simulation groups based on type of family witness: 1) no witness; 2) a quiet witness; 3) an overt reaction witness. All resuscitations were controlled in the simulation laboratory for time of resident entry, time of family witness entry, and time of cardiac rhythm changes regardless of interventions from physicians. The time to first defibrillation was significantly increased in the “overt reaction” witness group (2.57 min) compared to the quiet (1.77) and no family witness group (1.67). Also, the number of shocks delivered in the “overt reaction” witness group was 4.0, compared to 6.5 and 6.0 shocks in the quiet and no witness groups, respectively. The no witness group was the only group able to recognize the medication error verbalized in the resuscitation room. Each case was followed by a debriefing to identify the physicians' perceptions associated with witnessed resuscitations. Concerns included increased likelihood of litigation, traumatizing effect of event on family member, physician distraction by family member, and prolongation of resuscitation secondary to family member presence. Social worker presence was identified as an absolute necessity inside the rooms. This study suggested that the presence of family witnesses can impact patient care in a simulated setting by increasing time to critical events. Secondary to small sample size and a simulated environment, the authors note that more studies are needed to realize if this effect is similar in a clinical setting.

Life after Survival: Long-Term Daily Functioning and Quality of Life after an Out-Of-Hospital Cardiac Arrest: Wachelder EM, Moulaert VRMP, et al. Resuscitation 2009;80:517–22

Bonnie Kaplan — 2010-01-01

This retrospective cohort study at a Dutch University hospital examined 63 survivors of out-of-hospital cardiac arrest for participation in society and quality of life after their cardiac event. The authors hypothesized that out-of-hospital cardiac arrest survivors functioned at a lower level compared to the rest of the population. More specifically, they looked at physical, cognitive, and emotional impairment, daily functioning, and caregiver strain as secondary outcome measures. Sixty-three survivors and their caregivers, from January 2001 to December 2006, received a questionnaire by mail 3 years after their cardiac event. Two weeks after the first mailing a reminder was sent. The questionnaire to the participants included the New York Heart Association Classification, Fatigue Severity Scale, Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, Impact of Event Scale, Barthel Index measuring activities of daily living, Community Integration Questionnaire, Quality of Life survey, and Caregiver Strain Index. To assess the caregiver's status, they were asked to fill out their own Hospital Anxiety and Depression Scale, Impact of Event Scale, and the 36-item Short-form Health Survey. Initially, 1220 possible subjects were identified. Of these, only 88 were eligible secondary to death and loss to follow-up. Twenty-three didn't respond and 2 refused, leaving 63 participants. The final response rate was 72% of the 63 participants. The study found that 74% of the participants had a low participation level in society when compared to the rest of the Dutch population. Fifty percent of the participants also reported severe fatigue, 38% reported anxiety and depression, and 24% decreased quality of life. Of the caregivers, 17% reported high caregiver strain secondary to patient's lower level of functioning. In addition, percutaneous coronary intervention (PCI) was found to have a positive impact on societal participation and cognitive and daily function compared to patients without PCI (B 0.26, p = 0.03; B 0.31, p = 0.01; and B −0.32, p = 0.01, respectively). More cognitive problems were found in the participants treated with mild hypothermia (B 0.04 and p < 0.01). The authors concluded that participants who survived out-of-hospital cardiac arrests experienced more severe fatigue, anxiety, depression, cognitive problems, and decreased quality of life as compared to the general Dutch population.

Derivation of a Prognostic Score for Identifying Critically Ill Patients in an Emergency Department Resuscitation Room: Cattermole GN, Mak SKP, Liow CHE, et al. Resuscitation 2009;80:1000–5

Janetta Iwanicki — 2010-01-01

This prospective observational study conducted in an Emergency Department (ED) in Hong Kong aimed to develop a predictive score to determine which patients were most likely to become critically ill and were at high risk of requiring intensive care unit admission or dying within 7 days of ED presentation. A total of 330 eligible patients over age 18 years triaged to a resuscitation room within a 1-month period were included. Laboratory and physiologic parameters were analyzed using univariate analysis to determine which factors were most associated with a poor outcome. Multivariate analysis was then used to select 6 prognostic factors (systolic blood pressure, Glasgow Coma Scale, serum glucose, serum bicarbonate, white blood cell count, and history of metastatic cancer), each with statistical significance ≤ 0.05, and odds ratios utilized to derive the point score for the final prediction scale, the Prince of Wales Emergency Department Score (PEDS). This scale was compared to several other prognostic scores previously validated in other settings, including Acute Physiology and Chronic Health Evaluation, Revised Trauma Score, Rapid Emergency Medicine Score, and Modified Early Warning Score. None of these scores had been validated for predicting need for intensive care unit admission. In an area-under-the-curve analysis of receiver-operating-characteristic curves, PEDS had a significantly greater area under the curve than any of the other scores, indicating best prediction of poor outcome at 7 days consisting of intensive care admission or death (p < 0.001). The authors conclude that within the setting of this ED, the PEDS score is a useful tool to aid physicians in involving their intensive care colleagues early in patient care for appropriate disposition.

Subarachnoid Hemorrhage as a Cause of Out-of Hospital Cardiac Arrest: A Prospective Computed Tomography Study: Inamasu J, Miyatake S, Tomioka H, et al. Resuscitation 2009;80:977–80

Charles M. Reynolds — 2010-01-01

In this prospective, single-center study from Japan, 142 survivors of witnessed pre-hospital non-traumatic cardiac arrest from 2004 to 2007 received computed tomography (CT) of the head. Twenty-six (18.3%) of the 142 survivors had CT findings of intracranial hemorrhage, and 88% of these (or 16.2% overall) were found to have subarachnoid hemorrhage (SAH). In those patients with SAH, it was relatively severe, meeting criteria for Fisher grade III (8 patients) or IV (15 patients) classification. Patients with SAH tended to present with pulseless electrical activity (PEA) or asystole (52% and 43%, respectively) as the initial rhythm, whereas patients without SAH presented in either ventricular fibrillation or asystole (43% and 31%, respectively). Patients with SAH were less likely to have positive results on cardiac enzyme testing (5.3% vs. 41.7% in non-SAH group) and more likely to have had a headache before collapse (47.8% vs. 1.7%). Patients with SAH were much less likely to achieve return of spontaneous circulation in the field (13.0% vs. 34.5%) and to survive to hospital discharge (0% vs. 19.8%).

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2010-01-01